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From the 8/14/2018 release of VAERS data (an older release, current is 11/26/2021):

This is VAERS ID 413389

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Case Details

VAERS ID: 413389 (history)  
Form: Version 1.0  
Age: 79.0  
Sex: Female  
Location: Alabama  
Vaccinated:2010-10-21
Onset:2010-11-23
   Days after vaccination:33
Submitted: 2010-12-21
   Days after onset:28
Entered: 2010-12-22
   Days after submission:1
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
FLU3: INFLUENZA (SEASONAL) (FLUZONE) / SANOFI PASTEUR U3730AA / UNK LA / UN

Administered by: Private       Purchased by: Unknown
Symptoms: Balance disorder, Bradyphrenia, Feeling abnormal, Gait disturbance, Irritability, Mobility decreased, Nausea, Pyrexia, Vomiting
SMQs:, Acute pancreatitis (broad), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Dementia (broad), Parkinson-like events (broad), Psychosis and psychotic disorders (broad), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious encephalopathy/delirium (broad), Noninfectious meningitis (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hostility/aggression (broad), Vestibular disorders (broad), Tendinopathies and ligament disorders (broad), Drug reaction with eosinophilia and systemic symptoms syndrome (broad), Hypoglycaemia (broad)

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died: 2016-01-17
   Days after onset: 1881
Permanent Disability? No
Recovered? No
Office Visit? No
ER Visit? Yes
ER or Doctor Visit? No
Hospitalized? No
Previous Vaccinations: Swelling~Pneumo (no brand name)~UN~0.00~Patient|Injection site mass~Pneumo (no brand name)~UN~0.00~Patient
Other Medications: Prednisone; blood pressure pill; Vitamin B12
Current Illness:
Preexisting Conditions: History of increased blood pressure, and temporal arteritis (3 years). Additionally, the patient reported that 5 years earlier she had experienced "swelling and a hard knot" following vaccination with pneumonia vaccine.
Allergies:
Diagnostic Lab Data:
CDC Split Type: 201007010

Write-up: This case was initially reported by a consumer, who is also the patient, on 15 December 2010. A 79-year-old female patient received an INFLUENZA VACCINE (manufacturer reported as "possibly Sanofi Pasteur", lot not reported) in the left arm on 22 November 2010. The patient had a history of increased blood pressure and temporal arteritis (for past 3 years); she had previously experienced swelling and a hard knot at the site of a pneumococcal vaccine, and had received numerous influenza vaccines in the past. Concomitant medications included prednisone, a blood pressure pill, and Vitamin B12 1000mg. According to the patient, approximately 6 hours post-vaccination she began experiencing fever, nausea, vomiting, and difficulty in moving. Approximately 12 hours post-vaccination, she had a fever of 103 degrees and was unable to get out of bed. She was seen by a physician the day after vaccination, at which time she complained of difficulty walking and "brain function problem", described as fuzziness, slow thinking process, and balance problems when walking. The patient noted that she had been seen by a "brain doctor". Outcome was not reported.


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